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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376100463
Report Date: 08/30/2021
Date Signed: 08/30/2021 02:03:59 PM

Document Has Been Signed on 08/30/2021 02:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:KHADEM HOSSEIN, RAHIMA FAMILY CHILD CAREFACILITY NUMBER:
376100463
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
08/30/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Rahima Khden HosseiniTIME COMPLETED:
02:15 PM
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On 8/30/21 at 1:45 PM Licensing Program Analyst (LPA) Adrian Mangina conducted a Plan of Correction visit to the child care home to follow-up on deficiency cited during annual inspection on 8/16/2. LPA verified that the fire alarm located in the hallway is operational and meets requirements.

No deficiencies were cited during this visit.

Licensee was provided with a copy of this report (LIC809) and Appeal Rights. Her signature on this form is acknowledgement of receipt. A Notice of Site Visit (LIC9213 was also provided and must be posted for 30 consecutive days.
SUPERVISORS NAME: Renesha Pack
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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